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The Fast/Slow Paradox
Date: May 14, 2012
Faster is better. Except of course when slower is better.
In clinical medicine, these two maxims are in perpetual competition. We ignore either one at our patients’ peril. Two patients, similar in many ways, bring this paradox to life.
Sarah is 51 years old. She is a factory worker, a single mother of three, and a chain-smoker to the tune of two packs of Marlboro Reds per day. At 7 pm on a Thursday night, she stopped at a gas station to fill her pick-up truck. While pumping gas, she felt a sudden, intense nausea, accompanied by chest pressure. “What the hell was in that chicken casserole I had for lunch?” she thought. She walked up to the cashier, now in a drenching cold sweat. That’s what she last remembers.
After Sarah collapsed, another customer had the wherewithal to immediately start CPR. When EMS arrived, an electrocardiogram (ECG) showed a lethal arrhythmia, ventricular fibrillation (VF). She received two defibrillatory shocks on the gas station floor. Her pulse returned. Rushed to the hospital, we shocked her heart four more times for recurrent VF after her arrival. She was taken emergently to the catheterization laboratory, where an interventional cardiologist opened her occluded coronary artery with a balloon, sucked out a clot, and propped open the artery with a stent. The key elements of her lifesaving care were implemented at a blistering pace with maximum efficiency. Faster was not only better, it was essential. To the relief of her children and her doctors, she was awake the next morning, feeling no pain, and asking how she got here.
So, should our default approach be “faster-is-better”? There are clinical situations in which it absolutely applies. Like for Sarah’s near-fatal heart attack. Because of that, the medical profession has the obligation to figure out how to most rapidly deliver those proven therapies to heart attack patients. However, “faster-is-better” does not apply to much of medicine. There are inescapable downsides to the faster-is-better approach to health care.
Like Sarah, George is in his 50s and smokes like a chimney. He prefers Newports, more for their price than for their taste. Through a combination of unlucky genes and hard living, he suffered two separate heart attacks in his 40s, and has two coronary stents to prove it. This past winter, he walked into the ER on a Wednesday night with chest pain. Despite a normal ECG, reassuring vital signs, and atypical symptom characteristics, George underwent a fast flurry of testing, including several subsequent electrocardiograms, half a dozen blood draws, and a nuclear heart scan, all while receiving eight different prescription medications and an admission to the hospital. My team met him the next day. His chest pain was no better, though he was less bothered by it given his morphine-induced grogginess. Over the next 45 minutes, a carefully taken history by my team’s attending uncovered the answer: After 20 years working for the same plumbing company as his family’s sole breadwinner, George had been laid off earlier in the week. His son had been arrested for drug distribution a day later. George was so stressed that he hadn’t eaten in three days, relying instead on Newports and Budweiser. His exhaustion and hopelessness had reached fever pitch. With no better place to go, he walked into the hospital. Thousands of dollars in rapidly delivered testing did nothing to help his symptoms or his situation, though he still thought to thank us for our “great care and all the tests that you guys have run since yesterday.” A 45-minute conversation with my attending about options and social services resources was at least a real start.
Too often, patients, administrators, plenty of doctors, and outside observers identify “quality care” via tragically flawed proxies like speed-of-care, tests performed, etc. Seeking to be comprehensive as a doctor should not mean comprehensively ordering every conceivable test that might be relevant.To do so is to confuse completeness with intellectual laziness or billing prowess.
Some of the best doctoring I’ve witnessed during my training takes the following form: A senior physician spends enough time with a patient to realize what they have and to figure out what tests they don’t need. Unfortunately, there is no structural incentive to spend that time, and certainly no financial incentive. Until we fundamentally rethink and then restructure the economics driving the medical care profession, very little will change. A reimbursement system with fee-for-service at its backbone financially incentivizes one of two unsavory scenarios: insufficient care (if reimbursement is inadequately low) or runaway, billing-centric care.
Asking physicians to both “ensure the hospital’s profitability/viability” and “to do the right thing for patients” are often, though admittedly not always, contradictory directives. Somehow the incentives should be better aligned. We can’t do the right thing without a viable system and we can’t have a viable system unless we do the right thing.
So, in medicine, which approach is better: faster or slower? George and Sarah each illustrate the answer. Doing the right thing requires a calculated balance between speed and restraint. The answer, I think, should be both. *